QUESTION: This is an authentic coding case for an outpatient Clinic case for Genitourinary diseases.

QUESTION: This is an authentic coding case for an outpatient Clinic case for Genitourinary diseases.Please review the documentation of the patient encounter and code the case. You may use ICD-10-CM including External Cause Codes, CPT, and HCPCS codes. ( There are 8 codes total) 63 year old Female presents for pre operative exam for hysteroscopy D&C polypectomy. No LMP recorded. Patient is postmenopausal. Last period around age 54. Began bleeding again. She had spotting in the middle of the night that she noticed. That week had continuous spotting , not even enough for a pantyliner, and when she wiped noticed blood. Since October, she has continued to have intermittent spotting, random days. The bleeding has become more frequent since January, and she reports almost daily “discharge.” She has a FH endometrial cancer in her mother at age 76. She was unable to be biopsied on two occasions in the clinic, and finally presented for small LEEP (after miso) with endometrial biopsy. Path demonstrated: Proliferative endometrium with fragments of benign polyp. She continues to have regular spotting and the decision was made to go to the OR for further evaluation and removal of the polyp.  Transvaginal ultrasound showed thickened endometrium up to 2cm and three fibroids, largest 2cm. Both ovaries normal.  Past Medical History Hypertension Anemia Hearing loss Tinnitus Fibroids Osteopenia GERD (gastroesophageal reflux disease) Concussion head injury Arthritis Metabolic syndrome Heart murmur Abnormal Pap smear of cervix around age 24; had cryo Past Surgical History Tonsillectomy Bone graft Fracture surgery Pelvic fracture surgery  Allergies: Benzoin  Review of Systems: Constitutional: WD, WN, in NAD Ears/Nose/Throat no complaints Cardiovascular: no complaints Respiratory: no complaints Gastrointestinal: no complaints Genitourinary:· no complaints Musculoskeletal: no complaints Neurologic: no complaints  Objective: There were no vitals taken for this visit. See vitals from last clinic visit. External Genitalia: No Lesions Vagina: No Lesions Pelvic Supports: Normal Cervix: stenotic, normal size (nullip) Uterus: small Size, nontender and mobile Adnexa: No Palpable Mass and No Tenderness Assessment: Post menopausal bleeding , with endometrial polyp on biopsy and family history of mother with endometrial cancer. Scheduled for hysteroscopy, D&C, polypectomy, possible LEEP(if need to get past stenosis).  Plan: Risks and benefits of procedure reviewed with patient today via telephone. We have actually had this discussion at her last visit as well. All other alternatives including nonsurgical options reviewed with patients. All questions answered.  Order CBC to be done Thursday.Anesthesia preop visit scheduled as well. She is particularly concerned about her jaw and general anesthesia. She has been told she would be a difficult intubation. I told her she could discuss regional anesthesia with the anesthesiologist.  Gynecologic Surgery Operative NotePreoperative Diagnosis: Post menopausal bleeding Suspected endometrial polypPost-operative Diagnosis: Post menopausal bleeding Suspected endometrial polypProcedure performed: Hysteroscopy, Dilation, and curettage Polypectomy EBL: 5 mlFluids:  PRBC 0 Platelets 0 Crystalloid 700 other 0Urinary Output: not calculatedDrains: none Implants(include size & make): noneSpecimens: Collected ,labelled and sent to pathology Type: 1- endometrial curettings, 2- endometrial polypsFindings: Large endometrial polyps filling cavity. At conclusion, no polyps visualized  Procedure in detail:The patient was taken to the Operating Room where adequate general anesthesia was obtained. Her bladder was drained, and she was prepped and draped in the usual sterile fashion in Allen stirrups. A time-out was taken, and her identity and planned procedure were confirmed. We also confirmed that her SCDs were in place and working. Antibiotics were not indicated.  A speculum was placed into the vagina and the cervix was exposed. A single tooth tenaculum was placed on the anterior lip of the cervix. The uterus sounded to 7 ern. The hysteroscope was inserted into the cervix, and using hydro-distension, it was advanced into the uterus until the uterine cavity was seen. A survey of the uterine cavity demonstrated the above-mentioned findings. The camera was removed and a polypectomy was performed using Randall-Stone forceps. Gentle curettage was then performed until a gritty texture was encountered. The camera was reinserted and showed two small remaining polyps .Gentle curettage was again performed until a gritty texture was encountered. The camera was reinserted and showed that the endometrial polyps had been removed in their entirety. All instruments were removed from the vagina. All counts were correct at the end of the case, and she was discharged to recovery in stable condition.  CLINICAL HISTORY: 63 year-old females last period at age 54, with post-menopausal bleeding and polyps suspected on endometrial biopsy. DIAGNOSIS: A. Endometrial polyps, excision: Benign endometrial polyps B. Endometrial curettings : Blood and minute strips of superficial inactive endometrial tissue, no significant pathologic alteration Fragments of endocervix, strips of squamous epithelium unattached to stroma and fragments of stroma, no significant pathologic alteration  GROSS DESCRIPTION: Received the following specimens in the Department of Pathology, labeled with the patient’s name and hospital # A. endometrial polyps B. Endometrial curettings  A. The specimen is received in formalin, designated “Endometrial polyps” and consists of multiple fragments of glistening, pink-red soft tissue, measuring 2.3 x 2.0x 0.3em in aggregate. The specimen is entirely submitted in cassette A1.B. The specimen is received fresh, designated “Endometrial curettings” and consists of a 2.8 x 1.5 x 0.2em aggregate of clotted blood and pink soft tissue fragments . The specimen is totally submitted in cassette B 1 Health ScienceScienceNursing HCMT 2025C Share QuestionEmailCopy linkComments (0)

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